Home Care Nursing
in Ontario
March 2011
Home Care Nursing in Ontario
Nurses play an integral role in the delivery of quality care in the home. Home nursing care is the
promotion of health, assessment, provision of care and treatment of health conditions by supportive,
preventive, therapeutic, palliative and rehabilitative means in order to attain or maintain optimal
function (Havens 2003). Home health nurses are committed to the provision of accessible, responsive
and timely care which allows people to stay in their homes with safety and dignity (Community Health
Nurses of Canada 2010).
Home Care in Ontario
Home Care is an array of services for people of all ages, provided in the home, workplace, schools and
other community settings such as clinics, that encompasses health promotion and teaching, curative
intervention, end-of-life care, rehabilitation, support and maintenance, social adaptation and
integration and support for the family caregiver (Canadian Home Care Association 2008, pviii).
The provision of home care allows Ontarians of all ages the opportunity to recover or manage their
health care issues and age at home surrounded by family, friends and their community to which they
can continue to make a meaningful contribution. Home care services help people with a frailty or with
acute, chronic, palliative or rehabilitative health care needs to independently live in their community
and co-ordinate and manage an admission to facility care when living in the community is not a viable
alternative.
Services within home care include nursing, personal support/homemaker, therapy (including
physiotherapy, occupational therapy, speech language pathology, social work, nutrition/dietetics),
medical supplies and equipment in the home. Home care in Ontario is delivered by service provider
agencies that have met high standards of excellence identified through a rigorous competitive process
and administered through the CCACs.
Home Care History
Publicly funded home care was formally established in Ontario in 1970 and is considered to be a new
and growing part of the formal health care system. Since establishment, the home care system has
experienced a number of changes, evolving and maturing to the comprehensive program of today.
Home care is a publicly funded, not a publicly insured, service. In Ontario, publicly funded home care
falls under the jurisdiction of the Ministry of Health and Long-Term Care (MOHLTC) and is locally
administered by 14 Community Care Access Centres (CCACs) across the province.1 CCACs are
accountable to the Local Health Integrated Networks (LHINs). CCACs serve to provide a simplified
service access point and are responsible for determining eligibility for and buying on behalf of
consumers the highest quality, best priced visiting professional and homemaker2 services provided at
home and in publicly-funded schools. CCACs also provide information and referral to the public on
community-related services and authorize admissions to long-term care homes(Canadian Home Care
Association 2008, p80).
1
A listing of CCACs can be found at http://www.ccacont.ca/Locator.aspx?MenuID=70&PostalCode=Enter%20Postal%20Code&LanguageID=1&EnterpriseID=15
2
Homemaker serves as the generic term to describe the person who provides personal care, homemaking services and/or
respite to enable the individual to remain at home in a safe and acceptable environment
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A standardized assessment process, the RAI-HC3, is used by CCAC case managers to determine eligibility
and for evaluating the needs, abilities and preferences of adult long stay, palliative and short stay
individuals in the community. The assessment serves to guide CCAC case managers in the allocation of
home care services/funding and serves as the basis for standardized data to inform evidence based care.
Any Ontarian that meets the eligibility criteria for publicly‐funded home care service can receive the
service. In 2009/10, approximately 603,000 individuals received 29,419,559 visits/hours of care at home
funded by the MOHLTC (Ontario Association of Community Care Access Centres 2010). While most
home care recipients are elderly (54% in 2009/10), there are a wide range of situations which involve
children (16% of those served in 2009/10) and young adults (30% in 2009/10) that, when appropriately
supported, enable individuals to remain integrated in their home communities (Ontario Association of
Community Care Access Centres 2010).
The OHCA additionally estimates that 150,000 Ontarians privately purchase an additional 20 million
visits/hours of home care services annually in order to remain at home (Ontario Home Care Association
2009). Often, this care is delivered by nurses and paid by employment insurance plans and/or
government programs (such as respite plans) and/or direct private purchase. The purchase of private
home care services may supplement the publicly funded system allowing individuals to remain at home
surrounded by family, friends. Privately purchased home care service often provides the vital few hours
of care and respite that enables families to continue their caregiving responsibilities – which many are
fulfilling while raising their children and holding a job (Ontario Home Care Association 2010).
Home Care Nursing
Nursing is an important component of home care programs. The practice of nursing is defined as ‘the
practice of promotion of health and the assessment of, the provision of, care for, and the treatment of,
health conditions by supportive, preventive, therapeutic, palliative and rehabilitative means in order to
attain or maintain optimal function”(Government of Ontario 1991).
Visiting nursing and community health nursing has a long history in Canada beginning in the early 17th
century, when nuns from religious orders arrived in Quebec to provide both direct care and disease
prevention services (Community Health Nurses' Initiatives Group 1998). Since that time, home health
nursing in Ontario has evolved in response to changing patterns of disease, population aging, health
system reform and changing social values.
Community health nursing is a specialty within the practice
of nursing that describes nurses who work outside the
hospital or long-term care facility. Nurses in this specialty
promote, protect and preserve the health of individuals,
families, groups, communities and populations – wherever
people live, work, learn, worship and play in a continuous
versus episodic process. Community health nurses view health as a resource and focus on capacities.
They:
• Marshal resources to support health by coordinating care and planning nursing services,
programs and policies
Home health nursing is a specialized
area of nursing practice in which the
nurse provides care in the client’s
home, school or workplace.
3
Resident Assessment Instrument – Home Care - is a standardized, multi-dimensional assessment system for determining client
needs, which includes quality indicators, client assessment protocols, outcome measurement scales and a case mix system.
(Central CCAC 2009 The Value of interRAI-HC for Planning)
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•
•
•
Have a unique understanding of the influence of the environmental context of health
Build partnerships based on primary health care principles, caring and empowerment
Combine specialized nursing, social and public health science with experiential knowledge (Diem
and Moyer 2003).
Home health nursing is a specialized area of nursing practice in which the nurse provides care in the
client’s home, school or workplace or other community settings. It is a unique field of nursing practice
that focuses on the provision of nursing care to acute, chronically ill and well clients of all ages while
integrating community health nursing principles that focus on health promotion, environmental,
psychosocial, economic, cultural and personal health factors affecting an individual’s and family’s health
status (Humphrey and Milone-Nuzzo 1996).
A home health nurse is a community health nurse who:
• combines knowledge from primary health care (including the determinants of health), nursing
science and social sciences
• focuses on prevention, health restoration, maintenance or palliation
• focuses on clients, their designated caregivers and their families
• integrates health promotion, teaching and counselling in clinical care and treatment
• initiates, manages and evaluates the resources needed for the client to reach optimal well-being
and function
• provides care in a home care clinic, the client’s home, school or workplace
• has a nursing diploma (applicable to RPN) or a degree (a baccalaureate degree in nursing)
(Community Health Nurses Association of Canada 2008, p8). Nurse Practitioners, Registered
Nurses in the Extended Class licensed to order and interpret diagnostic tests, communicate
diagnoses, prescribe pharmaceuticals and perform specific procedures, .are beginning to
practice within home care as well.
In the home setting, the nurse brings caring activities that generate trust and collaboration for both the
care of the client and the maintenance of health of the other family members. The nursing process
applied to home health-care includes assessment, nursing diagnosis, planning for care, intervention and
evaluation. These processes are often more complex given the nature of the setting, the additional
variables influencing the client and the family, and the need for integration of community health nursing
concepts.
The foundations of home health nursing include: 1) health promotion, and 2) illness prevention and
health protection (Community Health Nurses of Canada 2010, p12). The elements of home health
nursing that are central to practice are:
· Assessment, Monitoring and Clinical Decision Making
· Care Planning and Care Coordination
· Health Maintenance, Restoration & Palliation
· Teaching and Education
· Communication
· Relationships
· Building capacity (Community Health Nurses of Canada 2010, p8).
The home care nurse role requires advanced assessment and evaluation skills, effective communication
skills, sound judgement, effective documentation skills, flexibility, critical /creative thinking and self-
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direction. Home care nursing practice is complex requiring independent decision making, a diverse
knowledge base in order to manage the care of patients with a broad array of diagnoses across the
lifespan and the health-illness continuum. Home care nurses require a competency in technology and
the maturity to work confidently and autonomously. Individuals who receive nursing care today often
have more acute and complex needs, and an increasing amount of their care is provided in the home.
The Home Care Team
An efficient and effective home care system appropriately utilizes and integrates all members of the
team to achieve value and to assist Ontarians who wish to receive care at home and remain
independent. Providing the full array of home care services, including access to case management,
family physicians, nursing, therapies, community pharmacists and personal support is essential to
support good health outcomes. Each interdisciplinary member has a unique body of knowledge and
scope of practice which must be respected and leveraged in order to maximize their effectiveness for
client care.
In home care, nurses, as important members of the health care team, fulfil many responsibilities
including the role of case management and direct service delivery offering nursing care and treatment
for health problems; health information and resources to promote positive health behaviours; support
and counselling; referrals to other members of the health care team; and advocacy (Canadian Nurses
Association 1998).
Nursing Statistics
In 2010, there were 125,844 nurses employed in Ontario. Or these 93,916 (75%) were registered
nurses; 30,442 (24%) were registered practical nurses and 1,486 (1%) were nurse practitioners (College
of Nurses of Ontario 2010). The community sector4 employed 18.4% of nurses with home care nursing
being among the top five employers and positions (College of Nurses of Ontario 2010).
The Top 5
.... of 21 employers
.... positions in nursing
49.5% Acute Care Hospital
68.2% Staff Nurse
12.8% Long-Term Care Facility
3.7% Visiting Nurse
4.8% Complex Continuing Care/Rehabilitation Hospital
3.3% Case Manager
4.1% Nursing/Staffing Agency
3.3% Middle Manager
3.6% Addiction and Mental Health Centre/Psychiatric Hospital
2.9% Public Health Nurse
Compared to 2009, there were gains in the number of RNs and RPNs in all employment sectors, but no
major changes in the distribution of these nurses among the sectors. RNs continued to report hospitals
as the largest sector of employment at 64.9 per cent, followed by community settings at 19.0 per cent,
4
The CNO includes the following in the definition of community - Community Care Access Centre, Community Health Centre,
Community Mental Health Program, Hospice, Nursing/Staffing Agency, Physician Office/ Family Practice Unit, Public health
Unit/Department, Other Community
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and long-term care facilities at 8.1 per cent (College of Nurses of Ontario 2010). RPNs continued to
report hospitals as the largest sector of employment at 44.0 per cent, followed by long-term care at 36.4
per cent and community settings at 14.9 per cent (College of Nurses of Ontario 2010).
The Future Demand for Home Care Nursing
With the aging population and the increasing emphasis on care at home, the paradigm is expected to
shift from the hospital to the community. The Canadian Nurses Association predicts that two-thirds of
nurses in Canada will be working in the community in 2020 compared to 30 percent in 2006 (Villeneuve
and MacDonald 2006). Ontario can expect to experience a similar pattern.
The increasing shift of care and treatment to the home and community - coupled with a greater
complexity in the condition of patients - calls for the kind of highly skilled and professional care that
nurses are trained to provide. However, in Ontario, home nursing represented about one quarter of the
home care services in 2003/04 and has dropped to approximately 21 per cent of care in
2009/10(Ontario Home Care Association 2011). The rationale and impact of this shift to client
outcomes requires examination.
Research has demonstrated the efficacy of home care
Two-thirds of nurses in Canada will
interventions in terms of cost savings and quality of life for
be working in the community in 2020
the care recipient and family (Hollander and Chappell 2002;
compared to 30 percent in 2006.
Hollander 2003; VanderBent and Kuchta 2010). Specific to
nursing, a randomized controlled trial presented clear evidence that providing seniors with proactive
nursing health promotion compared to providing professional services on demand, resulted in enhanced
quality of life related to early identification and management of risks for adverse events (i.e. falls,
polypharmacy, depression, caregiver stress) at no additional expense (Markle-Reid et al. 2003).
It should be expected that home care nursing, as a component of the home care team, will be
increasingly in demand as the health system transforms to care in the community. Working as a team is
effective and ensures that the outcomes realized are greater than the sum of the parts – in other words,
value is realized. Within home care, various “constellations” of service providers must be supported to
work together to address Ontario’s health priorities. Nurses practice autonomously in the community
sector and, as members of the team, apply critical thinking decisions about performing essential care.
They consider the appropriate health provider for the individual based on a detailed assessment and the
consideration of the person’s future needs. Nurses undertake to provide accurate, clear and concise
information about a client’s condition when transferring care (College of Nurses of Ontario 2007, p1013).
Nurses are “globally acknowledged as the linchpin of the health care system” (Alameddine et al. 2006,
p65-86). As members of the home care team, home care nurses contribute to the success of new and
emerging health system and clinical priorities (eg. Transfer of more complex services such as dialysis,
chemotherapy, pain management and chronic ventilator care to the home) thereby supporting more
individuals to remain at home. The home care team is vital to ensuring the uptake of new system
priorities, including:
• Alternate Level of Care (ALC) reductions – by ensuring that time in the acute care setting is kept to
a minimum and recovery to self care at home is expedited
· Emergency Department avoidance – by providing proactive support to forestall a health related
crisis and hospital admission; and being available 24/7 to respond to care needs as they arise in the
community
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•
•
•
Palliative and end-of- life care – by supporting pain and symptom management and providing
caregiver support so that a person can have a peaceful death at home
Children’s treatment – by enabling children with health related risk (medical, developmental, social,
or mental) to maximize their potential both at home and at school
Chronic disease management – by proactively assisting individuals so they can effectively
self‐manage at home, circumventing the need for hospitalization, and delaying loss of function and
independence
Home care has a unique position in the health care system serving as a bridge between various health
settings supporting individuals of all ages across the full continuum of need. The integrated team of
providers operating within the full scope of practice is necessary to achieve the greatest outcomes for
individuals. Within this team, nurses will continue to play an active role in developing the best mix of
services, programs and standards of care to ensure the efficient use of resources and achieve value for
all individuals served.
About Ontario Home Care Association (OHCA)
The OHCA, the voice of home care in Ontario, is a membership association representing providers of quality home
care services from across Ontario. OHCA members represent an estimated 25,000 staff collectively serving
300,000 Ontarians per year. OHCA works with families as integral partners in the delivery of home care services
and as such estimates that 1.2 million Ontarians are impacted by members. OHCA is dedicated to promoting the
growth and development of the home and community health care sector by helping to shape health care policy,
supporting members to excel, and being a leading source of information on home and community care. OHCA
members are accredited through Accreditation Canada, CARF, and/or registered with the International Standards
Association (ISO).
For more information, contact:
Susan D. VanderBent, BA, BSW, MSW, MHSc, CHE
Executive Director
Phone: 905-543-9474
Fax: 905-545
Email: [email protected]
For the latest in news and information about the home care sector in Ontario, subscribe to the Ontario Home Care
Association’s “House Call” at www.homecareontario.ca.
©Ontario Home Care Association – Home Care Nursing
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References
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Deber. 2006. Where are nurses working? Employment patterns by sub-sector in Ontario, Canada. Healthcare
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Canadian Home Care Association. 2008. Portraits of home care. Ottawa, Ontario: Canadian Home Care Association.
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———. 2007. It takes a team. The Standard of Care 32 (4): 10-3.
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———. 2010. Private home care – a vital component of the health care continuum in Ontario. Ontario: Ontario
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———. 2009. Creating an Ontario home care rebate to prevent additional costs to the frail and elderly. Ontario:
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